Summary of ECG Abnormalities
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This summary of ECG abnormalities is part of the almostadoctor ECG series. For a more in depth explanation of ECG
abnormalities, see ECG abnormalities. To learn about the basic principle of an ECG, see Understanding ECGs
Abnormality ECG sign
Sinus rhythm regular p waves, and each p
wave is followed by a QRS.
60-100bpm
Sinus Tachycardia Same as above, except
>100bpm
Sinus bradycardia Same as above except
<60bpm
Right ventricular hypertrophy Negative QRS
Right ventricular hypertrophy Taller QRS
Transition point moved to
the left – equal sized R and S
(normally seen in V3/V4)
Left Ventricular Hypertrophy Small lead I QRS, negative
leads II and lead III QRS
Seen in Pathology
All leads None
(best to look
at the
rhythm
strip)
All leads Does not represent
(best to look cardiac patholoy. May be
at the a sign of anxiety,
rhythm dehydration, recent
strip) exercise, or general illness
(e.g. sepsis, pneumonia,
respiratory pathology,
other illness)
All leads This is normal in young fit
(best to look people
at the
rhythm
strip)
Lead I Because the cardiac axis
has shifted from 11-5
o’clock to 1-7 o’clock, thus
lead I which measures
laterally from right to left
now gets a negative
signal because the signal
is going from left to right.
This axis shift is called
right axis deviation.
Lead III – Because lead III measures
becomes vertically but also slightly
taller than left to right, and this is
lead II pretty much the exact
direction of the new
shifted axis. Lead II,
measuring from right arm
to left leg is no longer
lined up as well. This axis
shift is called right axis
deviation.
Equally
sized R and
S now seen
in V5/V6
Leads I-III Left axis deviation – this
is often the results of a
conduction defect, and
not an increased bulk of
left ventricular tissue.
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 Atrial fibrillation Absent P waves – just an
irregular baseline.
Irregularly Irregular, irregular
QRS (but QRS is normal
shape)
Might look messy! E.g.
Atrial Flutter Tachycardia
Can’t tell if T/P waves are
present – rhythm is too fast
(250bpm). Often associated
block; i.e. there are QRS
complexes at a lower rate
than the p waves
Atrial tachycardia >150bpm, p waves
superimposed over t waves
of preceding beat, normal
QRS
Junctional tachycardia P waves very close to QRS,
or no QRS visible. QRS is
normal
1st degree heart block PR interval >0.2s (one big
square)
1st Degree Heart Block
some? As well as no p waves,
the rhythm will be
irregularly irregular. There
Rhythm will be a fibrillating
strip baseline due to
uncoordinated activity.
The causes of atrial
Generally
fibrillation are:
1. Ischaemic heart
disease
2. Thyrotoxicosis
(hyperthyroidism)
3. Sepsis
4. Valvular heart
disease
5. Alcohol excess
6. PE
Note that AF can also co-
exist with complete heart
block, in which case the
QRS will be regular!
Rhythm There will be saw tooth p
strip waves that occur at
300bpm, but the QRS
Lead where complexes will only be at
p waves are 150, 100 or 75 bpm due to
most easily various blocks. The QRS
visible – can be regular or irregular.
you should It can be very difficult to
use drugs see t waves – what looks
to slow like a T wave will probably
down the just be a p wave. The p
heart rate to waves occur at very
see what is regular intervals.
going on
Any where p Caused by a foci of the
waves are atria (outside of the SA
best seen node) depolarising quickly
Anywhere Due to a ‘re-entry’ loop;
there is an area of
depolarisation near the
AV node; this not only
transmits a signal
throughout the rest of the
ventricles to depolarise
them
Allover – This is an AV node block
best in I or Can be caused by CAD,
V1 acute rheumatic carditis,
digoxin toxicity, or
electrolyte disturbance
It is NOT an medical
emergency
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 2nd degree heart block
Mobitz type 1 – Wencebach
Mobitz type 2
2:1 and 3:1 conduction
Complete (third degree) heart block
Progressive lengthening of
the PR interval followed by
absent QRS, then cycle
repeats. Cycles are variable
in length. R-R interval
shortens with lengthening of
PR interval
Absent QRS every now and
again
This is the ratio of P:QRS
90 P waves/min, only about
38 QRS/min, and not
relationship between the P
waves and the QRS
complexes. QRS will often
have an abnormal shape,
and be broad (>120ms).
However, the P-P intervals
will be regular, as will the R-R
intervals – they are just not
in time with each other. The
rhythm of the ventricles is the
escape rhythm.
Anywhere This can be an AV node
block (nearly always), or
an SA node block. usually
benign and generally
doesn’t require specific
treatment. can be caused
by CHD or acute MI.
It is usually symptomless,
but can present with:
–Dizziness / light-
headedness / syncope
Anywhere This can be an SA node
block, or far more
commonly infra-Hisian
block (distal block). It can
progress to complete
heart block, from which
there is often no escape
rhythm; and thus this
needs treatment! the
definitive treatment is an
implanted pacemaker.
Can be caused by CHD or
MI
Anywhere May require a pacemaker,
particularly if the rate is
slow
Best in II This is an AV node block.
and V1 Atrial activity will be
completely normal, but
this conductivity does not
pass into the ventricles.
This always indicates
underlying disease – the
disease is often fibrosis
rather than ischaemia, but
it can occur in MI.
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RBBB – right bundle branch block
LBBB – left bundle branch block
Sinus bradycardia
Sinus Tachycardia
Supraventricular rhythms
ECG may appear normal. In
some people there may be 2
R waves. This creates a
distinctive pattern:
V1 – there is an M shaped
QRS – this is sometimes
called an RSR pattern
V6 – there is a W shaped
QRS
Wide QRS (120ms)
V1 – there is an W shaped
QRS
V6 – there is a M shaped
QRS
Wide QRS (>120ms)
The axis can be deviated
either way in BBB’s, but it is
most commonly normal
Normal rhythm <60bpm
Normal rhythm >100bpm
This is any rhythm that
originates outside the
ventricle
These are infra-Hisian
blocks. In bundle branch
blockages, the wave of
depolarisation can still
reach the IV septum, then
the PR interval will be
normal – and it is.
However, the time taken
for the depolarisation to
spread throughout the
ventricles is longer –
thus QRS complex
duration is lengthened.
In the acute setting it may
be caused by MI
RBBB – may indicate right
sided disease. The two R
waves indicate the
depolarisation of the right
and left sides of the heart
at different times (the
right depolarises after the
left).
You can remember the
pattern with the word
MarroW – there is M in
V1, and W in v6, and the
‘rr’ tells you it is on the
right!
There is NOT specific
treatment, and it is often
caused by an atrial septal
defect.
In the acute setting it may
be caused by MI
LBBB – often indicates
left sided heart disease.
Remember the pattern
with WillaM.
Causes:
Aortic stenosis, dilated
cardiomyopathy, acute
MI, CAD
Symptoms:
Syncope, and in more
severe cases; heart
failure. Those with
syncope and / or heart
failure will usually be
treated with a
pacemaker.
Anywhere Associated with; athletic
training, fainting,
hypothermia, myxedema
(hypothyroidism), seen
immediately after MI
Anywhere Associated with; exercise,
fear, pain, haemorrhage,
thyrotoxicosis
Examples include:
–Sinus rhythms
–LBBB
–RBBB
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 Ventricular rhythms
(aka escape rhythms)
Atrial escape
Junctional escape
Ventricular escape
Accelerated idioventricular rhythm
Extrasystoles
(aka ectopics)
Inferior MI
(probably the right coronary artery)
Anterior MI
(probably the left anterior descending)
Wide QRS complexes Anywhere
Abnormal p wave (e.g. Anywhere This occurs when the SA
inverted) node fails to depolarise.
Normal QRS Instead, some other part
Some normal beats after the of the atrium depolarises
abnormal one and sends the signal to
the ventricles.
No p waves The escape occurs
Normal QRS somewhere at the AV
Slightly slow rate (max junction. It occurs when
75bpm) the rate of depolarisation
of the SA node falls below
the rate of the AV node,
thus the AV node starts
the beat instead. The
resulting bradycardia
reduces cardiac output
and can cause symptoms
similar to other
bradycardias such as:
–Dizziness
–Light-headedness
–Syncope
–Hypotension
Usually the bradycardia
can be tolerated as long
as it is above 50bpm
Two types: Somewhere along the line
–Many p waves per QRS the p waves isn’t getting
(complete heart block) conducted to the
–Occasional missing p wave, ventricles, and thus the
followed by long gap, and ventricles depolarise at
then a ventricular QRS, then their normal escape rate.
normal rhythm
Wide QRS Don’t confuse this with
Rhythm of about 75bpm ventricular tachycardia –
No p waves which requires a HR of
Abnormal T waves >125pbm. Otherwise it
looks very similar.
Usually benign and does
not need to be treated.
Also associated with MI
These are easy – they are the same as ventricular escapes, except that
where in escapes the escape beat comes after a pause in the rhythm, in
extrasystole, there is an abnormal beat earlier than expected.
The QRS complexes are the same as those of sinus rhythm, but there
are usually abnormal p waves that tend to come immediately before or
immediately after the QRS.
ST elevation II, III, aVF The ST elevation in these
(the inferior leads is often
leads) accompanied by ST
depression in the antero-
lateral leads – V1-V6,
and possibly in lead I and
aVL
ST elevation V2-5 – the This will also cause deep
anterior q waves. The presence of
leads Q waves implies a full
thickness infarction.
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 Posterior MI ST depression, tall R waves V1-V3 Posterior MI is unusual!
The changes that occur
are opposite to the
changes of other type of
MI. thus the tall R waves
are the opposite of Q
waves (remember Q
waves are negative), and
ST depression occurs in
place of ST elevation

ST elevation MI ST elevation >2mm in 2+ T wave Both factors, if they occur,

(STEMI) chest leads OR >1mm in 2+ inversion are usually permanent. In
limb leads, occurs a full thickness infarction
T-wave inversion (after within a few then there are
several hours) hours of MI, pathological Q waves,
Pathological Q waves (24 pathological and T wave inversion, but
hours +) Q waves in a non-full thickness MI
occur then there is only T wave
several days inversion. The
after initial differentiation between
MI full /thickness and non
full thickness is pretty
NSTEMI Pathological Q waves only much the same as ST
elevation / non-ST
elevation

Ventricular tachycardia Wide QRS, no p waves, T ? Can be difficult to

waves difficult to identify, differentiate from BBB.
rate >200bpm BBB has p waves, and a
QRS generally 120-160ms.
VT is more likely scenario
after MI, and has QRS
>160ms

Supraventricular tachycardia Narrow QRS

Ventricular fibrillation No discernable pattern, no Patient is very likely to

QRS, no P, no T lose consciousness –
thus the diagnosis is
easy!

Wolff-Parkinson-White SYndrome Delta waves present, right Accessory pathway,

axis deviation, short PR usually from the left atria
interval, short QRS to the left ventricle allows
direct transition of the
signal, bypassing the AV
node, hence the
shortened PR interval. It
has a risk of mortality as
it can cause re-entry
tachycardia; however,
most patients are
symptomless and live
with no problems.

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 The digoxin effect Depression of ST, inverted T
waves
Pericarditis T wave inversion (rare: also
ST elevation)
P pulmonale Tall ,peaked T waves, p wave
height >2mm in lead II
Bifid P waves (‘P-Mitrale’) P waves with two peaks,
broad – looks like an ‘M’;
hence the name ‘Mitrale’
Bi-phasic T waves T waves with t peaks
Prolonged QT interval Prolonged QT
Hyperkalaemia Wide, tall, ‘tented’ T waves,
shortened/absent ST
segment, small or absent p
waves, wide QRS
Left ventricular hypertrophy S wave in V1 or V2 >35mm AND R wave in V5 or V6
>35mm R in aVF >20mm
R in aVL
>11mm
Any chest lead >45mm
R in lead I >12mm
Pacemaker Occasional P waves, not
related to QRS, QRS precede
by large spike, QRS
complexes broad
Axis deviation
widespread This causes a sloping ST
segment that has a
‘reversed tick’ look. This
occurs because digoxin
blocks the na/K pump,
which increases
intracellular Ca2+
concentrations. (similarly,
ischaemia causes
reduced production of
ATP, and thus reduced
pump activity)
Widespread If ST elevation does
occur, then the ST waves
will appear ‘saddle
shaped’ thus helping you
to differentiate it from MI.
also, the elevation in MI
tends to be confined to a
certain area, but in
pericarditis, it is
widespread
Lead II Seen in cor pulmonale, or
pretty much anything that
causes right atrial
enlargement (or
hypertrophy) – such as
tricuspid stenosis or
pulmonary hypertension
? Left ventricular
hypertrophy
Can occur as a result of
MI
The corrected QT, is the
QT interval as it would be
at 60bpm. if this is long,
then there is a risk of
sudden cardiac death. It
can be congenital, but
also caused by drugs
? Can lead to VF and AF
? The large spike is
pacemaker stimulus. The
QRS’s are wide because
the stimulus originates in
the ventricles
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 Lead I Lead II Axis

+ + Normal

+ – LAD

– Either RAD

aVR should always be negative!

If it is positive, it is called north-west axis. it could be due to incorrect limb lead placement, dextrocardia, or artificial
pacing, due to the pacemaker wire – this enters the heart at the apex.
Carotid sinus pressure
By applying pressure to the carotid sinus you can stimulate the AV and SA nodes via vagal stimulation. This will
reduce the frequency of discharge of the SA node, and increase the time of conduction across the AV node.
Thus, by applying pressure to the carotid sinus you can:
Reduce the rate of some arrhythmias
Completely stop some arrhythmias
It will have NO EFFECT ON VENTRICULAR TACHYCARDIAS – thus is can help you differentiate these from
supraventricular tachycardias (SVT)

Applying the pressure reduces the frequency of QRS complexes, and allows the underlying atrial arrhythmia to
become more visible.

Related Articles
ECG Abnormalities
Understanding ECGs
Angiotensin II Receptor Blockers (ARBs)
Amiodarone
Cardiac Tamponade

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